Noma: a neglected scourge of children in sub-Saharan Africa

Abstract

Poverty is the single most important risk indicator for noma (cancrum oris), a severe gangrene of the soft and hard tissues of the mouth, face, and neighbouring areas. The risk factors associated with an increased probability of noma developing include the following: malnutrition, poor oral hygiene, and a state of debilitation resulting from human immunodeficiency virus (HIV) infection, measles, and other childhood diseases prevalent in the tropics. There are many similarities between noma and necrobacillosis of the body surface of wallabies (Macropus reforgriseus), and it is proposed that noma results from oral contamination by a heavy load of Bacteroidaceae (particularly Fusobacterium necrophorum) and a consortium of other microorganisms. These opportunistic pathogens invade oral tissues whose defences are weakened by malnutrition, acute necrotizing gingivitis, debilitating conditions, trauma, and other oral mucosal ulcers. The current escalation in the incidence of noma in Africa can be attributed to the worsening economic crisis in the region, which has adversely affected the health and well-being of children through deteriorating sanitation, declining nutritional status and the associated immunosuppression, and increased exposure to infectious diseases. Prevention of noma in Africa will require measures that address these problems, and most importantly, eliminate faecal contamination of foods and water supplies.

PIP: Noma (cancrum oris) is a severe gangrene of the soft and hard tissues of the mouth, face, and neighboring areas observed especially in children. Without the timely intervention of appropriate antibiotics, noma is almost always quickly fatal. Survivors of the disease may exhibit facial mutilation, impaired growth of the facial skeleton, nasal regurgitation of food, leakage of saliva, defective speech, and chewing difficulties. Noma is frequently seen in developing countries, especially in sub-Saharan Africa, where it occurs almost exclusively among poor children usually aged 3-10 years. It may be that noma results from oral contamination by a heavy load of Bacteroidaceae and a consortium of other microorganisms. The opportunistic pathogens invade oral tissues when an individual's immune response is compromised by malnutrition, acute necrotizing, gingivitis, debilitating conditions, trauma, and other oral mucosal ulcers. Accordingly, malnutrition, poor oral hygiene, and debilitation resulting from HIV infection, measles, and other childhood diseases prevalent in the tropics are factors associated with an increased probability of developing noma. Poverty, however, is the most important risk indicator for the condition. The current escalation in the incidence of noma in Africa can be attributed to the worsening economic crisis in the region. The prevention of noma in Africa will require measures which address these problems and, most importantly, eliminate the fecal contamination of food and water supplies.